51
|
Roy A, Kim M, Hawes R, Varadarajulu S. The clinical and cost implications of failed endoscopic hemostasis in gastroduodenal ulcer bleeding. United European Gastroenterol J 2016; 5:359-364. [PMID: 28507747 DOI: 10.1177/2050640616663570] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/19/2016] [Indexed: 11/16/2022] Open
Abstract
AIM The aim of this article is to evaluate the clinical and cost implications of failed endoscopic hemostasis in patients with gastroduodenal ulcer bleeding. METHODS A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) file was conducted to identify all hospitalizations for gastroduodenal ulcer bleeding in the year 2012. The main outcome measures were to compare all-cause mortality, total length of hospital stay (LOS), hospital costs and payment between patients managed with one upper gastrointestinal (UGI) endoscopy versus more than one UGI endoscopy or requiring interventional radiology-guided hemostasis (IRH) or surgery after failed endoscopic attempt. RESULTS The MedPAR claims data evaluated 13,501 hospitalizations, of which 12,242 (90.6%) reported one UGI endoscopy, 817 (6.05%) reported >1 UGI endoscopy, 303 (2.24%) reported IRH after failed endoscopy and 139 (1.03%) reported surgeries after failed endoscopy. All cause-mortality was significantly lower for patients who underwent only one UGI endoscopy (3%) compared to patients requiring >1 endoscopy (6%), IRH (9%) or surgery (14%), p < 0.0001. The median LOS was significantly lower for patients who underwent only one UGI endoscopy (four days) compared to patients requiring >1 endoscopy (eight days), IRH (nine days) or surgery (15 days), p < 0.0001. The median hospital costs were significantly lower for patients who underwent one UGI endoscopy ($10,518) compared to patients requiring >1 endoscopy ($20,055), IRH ($34,730) or surgery ($47,589), p < 0.0001. CONCLUSIONS Failure to achieve hemostasis at the index endoscopy has significant clinical and cost implications. When feasible, a repeat endoscopy must be attempted followed by IRH. Surgery should preferably be reserved as a last resort for patients who fail other treatment measures.
Collapse
Affiliation(s)
- Ann Roy
- Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA
| | - Micheline Kim
- Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA
| | | |
Collapse
|
52
|
Affiliation(s)
- Loren Laine
- From the Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven - both in Connecticut
| |
Collapse
|
53
|
Jian Z, Li H, Race NS, Ma T, Jin H, Yin Z. Is the era of intravenous proton pump inhibitors coming to an end in patients with bleeding peptic ulcers? Meta-analysis of the published literature. Br J Clin Pharmacol 2016; 82:880-9. [PMID: 26679691 DOI: 10.1111/bcp.12866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 11/27/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS Oral and intravenous proton pump inhibitors (PPIs) are equipotent in raising gastric pH. However, it is not known whether oral PPIs can replace intravenous PPIs in patients with bleeding peptic ulcers. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials to compare oral and intravenous PPIs among patients with peptic ulcer bleeding. A search of all major databases and relevant journals from inception to April 2015, without a restriction on languages, was performed. RESULTS A total of 859 patients from seven randomized controlled trials were included in the meta-analysis. Similar pooled outcome measures were demonstrated between the two groups in terms of oral PPIs vs. intravenous PPIs in the rate of recurrent bleeding within the 30-day follow-up period [risk ratio = 0.90; 95% confidence interval (CI): 0.58, 1.39; P = 0.62; I(2) = 0%). In terms of the rate of mortality, both oral and intravenous PPIs showed similar outcomes, and the pooled risk ratio was 0.88 (95% CI: 0.29, 2.71; P = 0.82; I(2) = 0%). Likewise, no significant difference was detected in the need for blood transfusion and length of hospital stay; the pooled mean differences were -0.14 (95% CI: -0.39, 0.12; P = 0.29; I(2) = 32%) and -0.60 (95% CI: -1.42, 0.23; P = 0.16; I(2) = 79%), respectively. CONCLUSIONS Our results suggest that oral PPIs are a feasible, safe alternative to intravenous PPIs in patients with bleeding peptic ulcers, and may be able to replace intravenous PPIs as the treatment of choice in these patients.
Collapse
Affiliation(s)
- Zhixiang Jian
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hui Li
- Neurological Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Nicholas S Race
- Purdue University Weldon School of Biomedical Engineering, Indiana University School of Medicine, B.S. Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Tingting Ma
- Gynaecology and Obstetrics Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haosheng Jin
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zi Yin
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
54
|
Antroduodenectomy with Gastroduodenal Anastomosis: Salvage Emergency Surgery for Complicated Peptic Ulcer Disease--Results of a Double Institution Study of 35 Patients. J Gastrointest Surg 2016; 20:539-45. [PMID: 26643299 DOI: 10.1007/s11605-015-3050-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/29/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic and interventional techniques are currently the mainstay of management of bleeding duodenal ulcer. As well, for patients with perforated duodenal ulcer, laparoscopic simple closure is nowadays usually performed. Although indications for emergency antroduodenectomy have declined, this procedure is still necessary as a salvage option when conservative management has failed or is not practicable. Our study aimed to evaluate indications and results of antroduodenectomy with gastroduodenal anastomosis in current practice and to examine the factors that predict operative outcomes. METHODS All patients who underwent emergency antroduodenectomy with gastroduodenal anastomosis in two surgical care departments specialized in emergency digestive surgery were studied from 2000 to 2015. RESULTS Thirty-five patients (27 males, 77 %) with a median age of 68 years (20-90) underwent emergency antroduodenectomy with gastroduodenal anastomosis. Indications were bleeding and perforated duodenal ulcer in 24 and 11 patients, respectively. The overall complication rate was 69 %, especially because of a high rate of medical complications (57 %). Only two patients (6 %) required reoperation for anastomotic leakage. The overall mortality rate was 40 % (n = 14). According to the univariate analysis, age >70, >3 comorbidities, ASA score >2, and postoperative medical complications were associated with an increased risk of in-hospital mortality. In the multivariate analysis, age and ASA score remained independent risk factors. No recurrence of complicated duodenal disease was observed. CONCLUSION Antroduodenectomy with gastroduodenal anastomosis is a safe and effective long-term strategy, with a low and acceptable rate of surgical complications, for complicated duodenal ulcer not responding to conservative measures.
Collapse
|
55
|
Abstract
In the intensive care unit, vigilance is needed to manage nonvariceal upper gastrointestinal bleeding. A focused history and physical examination must be completed to identify inciting factors and the need for hemodynamic stabilization. Although not universally used, risk stratification tools such as the Blatchford and Rockall scores can facilitate triage and management. Urgent evaluation for nonvariceal upper gastrointestinal bleeds requires prompt respiratory assessment, and identification of hemodynamic instability with fluid resuscitation and blood transfusions if necessary. Future studies are needed to evaluate the indication, safety, and efficacy of emerging endoscopic techniques.
Collapse
|
56
|
Intraoperative salvage endoscopy performed during orthotopic liver transplantation due to esophageal bleeding. Wideochir Inne Tech Maloinwazyjne 2015; 10:472-6. [PMID: 26649098 PMCID: PMC4653274 DOI: 10.5114/wiitm.2015.54559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/28/2015] [Accepted: 09/17/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction Liver transplantation (LTx) is a widely accepted method of treatment for end stage liver diseases. There are many reports on the management of gastrointestinal bleeding (GIB) after LTx, however the number of studies concerning salvage endoscopic procedures during LTx are scarce. Aim We present our material of intraoperative endoscopic procedures due to GIB during LTx. Material and methods During this period there were 4 females and 1 male at the mean age of 52.2 (35–65) years who underwent LTx and 1 patient had Re-LTx. All patients were Child-Pugh group C and mean MELD score was 17.75. Esophageal and/or gastric varices were present before surgery in all patients but only 1 female patient didn't experience GIB prior to LTx. Variables such as operating time, cold ischemic time, blood loss, blood transfusion, PLT count, international normalized ratio, albumin levels were similar in all patients thus making it statistically insignificant as the cause of GIB. Results In all cases a single IOE was necessary and bleeding from ruptured varices succumbed to endoscopic ligation. In 2 patients besides trials of ligating the varix, histoacryl was put in use which proved success. In both these last female patients the endoscopic physician had to insert a Danis stent. A follow up endoscopy was performed on the 7–10 POD. Conclusions Intra-operative endoscopy performed during LTx does not interrupt surgery. Performed as soon as possible results in less future endoscopic interventions due to GIB. Intraoperative endoscopy may be considered as a salvage procedure and should be performed in the shortest possible time.
Collapse
|
57
|
Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer. J Clin Gastroenterol 2015; 49:738-45. [PMID: 25319738 DOI: 10.1097/mcg.0000000000000259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
GOALS The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. BACKGROUND TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. STUDY This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. RESULTS The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. CONCLUSIONS Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.
Collapse
|
58
|
Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson P, Gehin S, Cercueil J, Krausé D. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96:731-44. [DOI: 10.1016/j.diii.2015.05.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/06/2015] [Indexed: 02/08/2023]
|
59
|
Abstract
Peptic ulcer bleeding is a common emergency. Management of ulcer bleeding requires prompt risk stratification, initiation of pharmacotherapy, and timely evaluation for endoscopy. Although endoscopy can achieve primary hemostasis in more than 90% of peptic ulcer bleeding, rebleeding may occur in up to 15% of patients after therapeutic endoscopy and is associated with heightened mortality. Early identification of high-risk patients for rebleeding is important. Depending on bleeding severity and center availability, patients with rebleeding may be managed by second endoscopy, transarterial angiographic embolization, or surgery. This article reviews the current management of peptic ulcers with an emphasis on rebleeding.
Collapse
Affiliation(s)
- Sunny H Wong
- State Key Laboratory of Digestive Disease, Faculty of Medicine, Institute of Digestive Disease, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China
| | - Joseph J Y Sung
- State Key Laboratory of Digestive Disease, Faculty of Medicine, Institute of Digestive Disease, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China.
| |
Collapse
|
60
|
Loh DC, Wilson RB. Endoscopic management of refractory gastrointestinal non-variceal bleeding using Histoacryl (N-butyl-2-cyanoacrylate) glue. Gastroenterol Rep (Oxf) 2015; 4:232-6. [PMID: 25991813 PMCID: PMC4976680 DOI: 10.1093/gastro/gov019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023] Open
Abstract
Background: Histoacryl glue (N-butyl-2-cyanoacrylate) has well-established utility in the endoscopic management of gastrointestinal variceal bleeding. The role of Histoacryl glue in non-variceal bleeding is less clear, and there are few articles describing its use in this setting. Methods: Six patients with intractable non-variceal gastrointestinal bleeding were managed using injection of Histoacryl glue. All patients had previously failed conventional endostasis and/or interventional angioembolization and were not suitable for emergency salvage surgery due to serious comorbidities or unacceptable anaesthetic risk. An endoscopic Lipiodol-Histoacryl-Lipiodol sandwich injection technique was used in these patients. The clinical outcomes and complications were evaluated. Results: There were four females and two males with a mean age of 55 years. Bleeding lesions included gastric ulcers (n = 2), duodenal ulcers (n = 2), duodenal gastrointestinal stromal tumor (GIST) (n = 1) and rectal ulcers (n = 1). All patients had successful Histoacryl endostasis without the requirement for salvage surgery. There was no treatment-related morbidity and no mortality. Two patients had further bleeding after initial Histoacryl endostasis, which was successfully controlled with further endoscopic Histoacryl injection. Conclusion: Histoacryl endostasis should be included in the treatment algorithm for refractory non-variceal gastrointestinal bleeding.
Collapse
Affiliation(s)
- Damien Ck Loh
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Sydney, Australia
| | - Robert B Wilson
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Sydney, Australia
| |
Collapse
|
61
|
Kim JS, Park SM, Kim BW. Endoscopic management of peptic ulcer bleeding. Clin Endosc 2015; 48:106-11. [PMID: 25844337 PMCID: PMC4381136 DOI: 10.5946/ce.2015.48.2.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/06/2015] [Accepted: 03/11/2015] [Indexed: 01/14/2023] Open
Abstract
Acute upper gastrointestinal bleeding is a common medical emergency around the world and the major cause is peptic ulcer bleeding. Endoscopic treatment is fundamental for the management of peptic ulcer bleeding. Despite recent advances in endoscopic treatment, mortality from peptic ulcer bleeding has still remained high. This is because the disease often occurs in elderly patients with frequent comorbidities and are taking ulcerogenic medications. Therefore, the management of peptic ulcer bleeding is still a challenge for clinicians. This article reviews the various endoscopic methods available for management of peptic ulcer bleeding and the techniques in using these methods.
Collapse
Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sung Min Park
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| |
Collapse
|
62
|
Kim YI, Choi IJ. Endoscopic management of tumor bleeding from inoperable gastric cancer. Clin Endosc 2015; 48:121-7. [PMID: 25844339 PMCID: PMC4381138 DOI: 10.5946/ce.2015.48.2.121] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 01/10/2023] Open
Abstract
Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.
Collapse
Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| |
Collapse
|
63
|
|
64
|
Park WG, Shaheen NJ, Cohen J, Pike IM, Adler DG, Inadomi JM, Laine LA, Lieb JG, Rizk MK, Sawhney MS, Wani S. Quality indicators for EGD. Gastrointest Endosc 2015; 81:17-30. [PMID: 25480101 DOI: 10.1016/j.gie.2014.07.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
|
65
|
Chiu PWY, Lau JYW. What if endoscopic hemostasis fails?: Alternative treatment strategies: surgery. Gastroenterol Clin North Am 2014; 43:753-63. [PMID: 25440923 DOI: 10.1016/j.gtc.2014.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.
Collapse
Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China.
| | - James Yun Wong Lau
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China
| |
Collapse
|
66
|
Lu Y, Chen YI, Barkun A. Endoscopic management of acute peptic ulcer bleeding. Gastroenterol Clin North Am 2014; 43:677-705. [PMID: 25440919 DOI: 10.1016/j.gtc.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.
Collapse
Affiliation(s)
- Yidan Lu
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada; Division of Clinical Epidemiology, McGill University Health Center, McGill University, 687 Pine Avenue West, Montréal H3A 1A1, Canada.
| |
Collapse
|
67
|
Sverdén E, Sondén A, Leinsköld T, Lagergren J, Lu Y. Minimal versus definitive surgery in managing peptic ulcer bleeding: a population-based cohort study. Dig Surg 2014; 31:276-82. [PMID: 25322774 DOI: 10.1159/000365336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/15/2014] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To compare radical surgery with a minimal approach for peptic ulcer bleeding in relation to survival. DESIGN A Swedish nationwide population-based cohort study from 1987-2008 compared survival after minimal surgery and definitive surgery. The cohort was also stratified into calendar year before and after the year 2000 for subgroup analyses. Data were collected from the Swedish Patient Register. The two surgical groups were matched based on the propensity score to mimic a randomized trial design. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models adjusted for potential confounders. RESULTS 4,163 patients were included. There were no differences in survival in patients who underwent definitive surgical procedures compared to those who underwent minimal surgery for a bleeding peptic ulcer during the full study period. Using minimal surgery group as the reference, the HRs for death in the definitive surgery group within 30 days, 90 days, 1 year, and 5 years were 0.87 (95% CI 0.72-1.05), 0.93 (0.80-1.09), 1.00 (95% CI 0.87-1.14), and 1.05 (95% CI 0.95-1.16), respectively. The corresponding HRs during the calendar period after the year 2000 were 1.05 (95% CI 0.65-1.69), 1.18 (95% CI 0.81-1.73), 1.17 (0.84-1.62), and 1.27 (95% CI 0.99-1.63), respectively. CONCLUSION This study found no worse overall survival after minimal surgery compared to more extensive surgery for refractory peptic ulcer bleeding, and indicated better long-term survival in the minimal surgery group during the more recent study period. A minimal approach is probably sufficient in most cases.
Collapse
Affiliation(s)
- Emma Sverdén
- Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | |
Collapse
|
68
|
Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014; 9:45. [PMID: 25114715 PMCID: PMC4127969 DOI: 10.1186/1749-7922-9-45] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/26/2014] [Indexed: 12/11/2022] Open
|
69
|
Di Saverio S, Bassi M, Smerieri N, Masetti M, Ferrara F, Fabbri C, Ansaloni L, Ghersi S, Serenari M, Coccolini F, Naidoo N, Sartelli M, Tugnoli G, Catena F, Cennamo V, Jovine E. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014. [PMID: 25114715 DOI: 10.1186/1749-7922-9-451749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salomone Di Saverio
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Marco Bassi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy.,Liver and Multivisceral Transplantation Unit, University of Modena&Reggio Emilia - Policlinico Hospital, Modena, Italy
| | - Michele Masetti
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Carlo Fabbri
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Stefania Ghersi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Matteo Serenari
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Federico Coccolini
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Noel Naidoo
- Port Shepstone Regional Hospital, Port Shepstone, South Africa - Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gregorio Tugnoli
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Dept., Maggiore Hospital of Parma, Parma, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Elio Jovine
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| |
Collapse
|
70
|
Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding. Wideochir Inne Tech Maloinwazyjne 2014; 9:489-93. [PMID: 25337181 PMCID: PMC4198650 DOI: 10.5114/wiitm.2014.44169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/10/2014] [Accepted: 05/20/2014] [Indexed: 12/20/2022] Open
Abstract
Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.
Collapse
|
71
|
Beggs AD, Dilworth MP, Powell SL, Atherton H, Griffiths EA. A systematic review of transarterial embolization versus emergency surgery in treatment of major nonvariceal upper gastrointestinal bleeding. Clin Exp Gastroenterol 2014; 7:93-104. [PMID: 24790465 PMCID: PMC3998850 DOI: 10.2147/ceg.s56725] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Emergency surgery or transarterial embolization (TAE) are options for the treatment of recurrent or refractory nonvariceal upper gastrointestinal bleeding. Surgery has the disadvantage of high rates of postoperative morbidity and mortality. Embolization has become more available and has the advantage of avoiding laparotomy in this often unfit and elderly population. Objective To carry out a systematic review and meta-analysis of all studies that have directly compared TAE with emergency surgery in the treatment of major upper gastrointestinal bleeding that has failed therapeutic upper gastrointestinal endoscopy. Methods A literature search of Ovid MEDLINE, Embase, and Google Scholar was performed. The primary outcomes were all-cause mortality and rates of rebleeding. The secondary outcomes were length of stay and postoperative complications. Results A total of nine studies with 711 patients (347 who had embolization and 364 who had surgery) were analyzed. Patients in the TAE group were more likely to have ischemic heart disease (odds ratio [OR] =1.99; 95% confidence interval [CI]: 1.33, 2.98; P=0.0008; I2=67% [random effects model]) and be coagulopathic (pooled OR =2.23; 95% CI: 1.29, 3.87; P=0.004; I2=33% [fixed effects model]). Compared with TAE, surgery was associated with a lower risk of rebleeding (OR =0.41; 95% CI: 0.22, 0.77; P<0.0001; I2=55% [random effects]). There was no difference in mortality (OR =0.70; 95% CI: 0.48, 1.02; P=0.06; I2=44% [fixed effects]) between TAE and surgery. Conclusion When compared with surgery, TAE had a significant increased risk of rebleeding rates after TAE; however, there were no differences in mortality rates. These findings are subject to multiple sources of bias due to poor quality studies. These findings support the need for a well-designed clinical trial to ascertain which technique is superior.
Collapse
Affiliation(s)
- Andrew D Beggs
- Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Mark P Dilworth
- Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Susan L Powell
- Department of Geriatric Medicine, Heart of England NHS Foundation Trust, Solihull Hospital, Birmingham, UK
| | - Helen Atherton
- Department of Primary Health Care Health Sciences, University of Oxford, Oxford, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
72
|
Griffiths EA, McDonald CR, Bryant RV, Devitt PG, Bright T, Holloway RH, Thompson SK. Retrospective analysis of surgery and trans-arterial embolization for major non-variceal upper gastrointestinal bleeding. ANZ J Surg 2014; 86:381-5. [DOI: 10.1111/ans.12588] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2014] [Indexed: 01/27/2023]
Affiliation(s)
- Ewen A. Griffiths
- Professorial Unit of Oesophagogastric Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Chris R. McDonald
- Department of Surgery; Flinders Medical Centre; Adelaide South Australia Australia
| | - Robert V. Bryant
- Department of Gastroenterology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Peter G. Devitt
- Professorial Unit of Oesophagogastric Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Tim Bright
- Department of Surgery; Flinders Medical Centre; Adelaide South Australia Australia
| | - Richard H. Holloway
- Department of Gastroenterology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Sarah K. Thompson
- Professorial Unit of Oesophagogastric Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| |
Collapse
|
73
|
Kyaw M, Tse Y, Ang D, Ang TL, Lau J. Embolization versus surgery for peptic ulcer bleeding after failed endoscopic hemostasis: a meta-analysis. Endosc Int Open 2014; 2:E6-E14. [PMID: 26134614 PMCID: PMC4423253 DOI: 10.1055/s-0034-1365235] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 01/04/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS A meta-analysis was conducted to assess the efficacy of transcatheter arterial embolization (TAE) compared with surgery in the management of patients with recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB) after failure of endoscopic hemostasis. PATIENTS AND METHODS Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts from major international conferences were searched for studies comparing TAE with surgery for treatment of NVUGIB after endoscopic hemostasis failure. Outcome measures included rebleeding rate, all-cause mortality rate, and need for additional interventions to secure hemostasis. RESULTS From 1234 citations, 6 retrospective comparative studies were included that involved 423 patients (TAE, 182, 56 % male; surgery, 241, 68 % male). TAE patients were older (mean age, TAE 75, surgery, 68). The risk of rebleeding was significantly higher in TAE patients compared with surgically treated patients (relative risk [RR] 1.82, 95 % confidence interval [95 %CI] 1.23 - 2.67), with no statistically significant heterogeneity among the included studies (P = 0.66, I (2) = 0.0 %). After sensitivity analysis excluding studies with a large age difference between the two groups, a higher risk of bleeding remained in the TAE group (RR 2.64, 95 %CI] 1.48 - 4.71). No significant difference in mortality (RR 0.87, 95 %CI 0.59 - 1.29) or requirement for additional interventions (RR 1.67, 95 %CI 0.75 - 3.70) was shown between the two groups. CONCLUSION A higher rebleeding rate was observed after TAE, suggesting surgery more definitively secured hemostasis, with no significant difference in mortality rate or requirement of additional interventions. The TAE patients were older and in poorer health, thus future randomized studies are needed for accurate comparison of the two modalities.
Collapse
Affiliation(s)
- Moe Kyaw
- Institute of Digestive Diseases, Chinese University of Hong Kong, Shatin, Hong Kong,Corresponding author Moe Kyaw, MBBS, MSc, MRCP, MBA Institute of Digestive DiseasesThe Chinese University of Hong KongPrince of Wales HospitalShatinHong Kong
| | - Yee Tse
- Institute of Digestive Diseases, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Daphne Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - James Lau
- Institute of Digestive Diseases, Chinese University of Hong Kong, Shatin, Hong Kong
| |
Collapse
|
74
|
Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
Collapse
Affiliation(s)
- Y Lu
- Division of Gastroenterology and
| | | | | | | |
Collapse
|
75
|
Wierzchowski P, Dabrowiecki S, Szczesny W, Szmytkowski J. Nonvariceal upper gastrointestinal tract bleeding - risk factors and the value of emergency endoscopy. Arch Med Sci 2013; 9:843-8. [PMID: 24273567 PMCID: PMC3832819 DOI: 10.5114/aoms.2013.36911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/15/2012] [Accepted: 05/11/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Upper gastrointestinal tract bleeding (UGIB) remains a valid issue of modern medicine. The mortality and recurrence rates remain high and have not decreased as expected over the past decades. AIM OF THE STUDY to assess the treatment outcomes of nonvariceal UGIB depending on the timing of endoscopy (urgent vs. elective) and to perform an analysis of risk factors for death in patients with nonvariceal UGIB. MATERIAL AND METHODS Comparative evaluation of treatment outcomes in two groups of patients. Group A consisted of patients undergoing elective endoscopy (n = 187). Group B consisted of patients undergoing emergency endoscopy (n = 295). Moreover, the influence of selected factors on the risk of death and bleeding recurrence was analyzed in the combined population of the two groups. This was done by constructing a logistic regression model and testing dependence hypotheses. RESULTS In group A the mortality rate was 9.1%, and the recurrence rate was 18.2%. In group B the values were 6.8% and 12.2%, respectively. No statistically significant difference was found (p = NS). In group B the number of surgical interventions, blood transfusions and intensive care admissions was significantly lower (p < 0.05). An analysis of the combined material showed that the factors which correlated with an elevated risk of death included: old age, hemodynamic state (shock), elevated Charlson Comorbidity Index score, hemoglobin concentration, bleeding from a malignant lesion, recurrent bleeding and the need for surgery (p < 0.05). CONCLUSIONS The use of emergency endoscopy improves the treatment outcomes in patients with UGIB, although no statistically significant decrease in the mortality and recurrence rates could be observed.
Collapse
Affiliation(s)
- Pawel Wierzchowski
- Department of General and Endocrine Surgery, University Hospital No. 1, Bydgoszcz, Poland
| | | | | | | |
Collapse
|
76
|
Wong SH, Sung JJY. Management of GI emergencies: peptic ulcer acute bleeding. Best Pract Res Clin Gastroenterol 2013; 27:639-47. [PMID: 24160924 DOI: 10.1016/j.bpg.2013.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/18/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.
Collapse
Affiliation(s)
- Sunny H Wong
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong.
| | | |
Collapse
|
77
|
Navuluri R, Patel J, Kang L. Role of interventional radiology in the emergent management of acute upper gastrointestinal bleeding. Semin Intervent Radiol 2013; 29:169-77. [PMID: 23997408 DOI: 10.1055/s-0032-1326925] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Approximately 100,000 cases of upper gastrointestinal bleeding (UGIB) require inpatient admission annually in the United States. When medical management and endoscopic therapy are inadequate, endovascular intervention can be lifesaving. These emergent situations highlight the importance of immediate competence of the interventional radiologist in the preangiographic evaluation as well as the endovascular treatment of UGIB. We describe a case of UGIB managed with endovascular embolization and detail the angiographic techniques used. The case description is followed by a detailed discussion of the treatment approach to UGIB, with attention to both nonvariceal and variceal algorithms.
Collapse
Affiliation(s)
- Rakesh Navuluri
- Department of Radiology, the University of Chicago Medical Center, Chicago, Illinois
| | | | | |
Collapse
|
78
|
Walia SS, Sachdeva A, Kim JJ, Portocarrero DJ, Lewis TD, Zhao YS. Cyanoacrylate spray for treatment of difficult-to-control GI bleeding. Gastrointest Endosc 2013; 78:536-9. [PMID: 23948199 DOI: 10.1016/j.gie.2013.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 05/10/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although endoscopic therapy is highly effective for control of GI bleeding, a small proportion of patients experience persistent bleeding and may require radiologic or surgical intervention. Experience with cyanoacrylate spray for treatment of difficult-to-control GI bleeding is limited. OBJECTIVE To evaluate the efficacy and safety of an endoscopic cyanoacrylate spray technique for treatment of difficult-to-control GI bleeding. DESIGN Case series. SETTING Two tertiary-care centers. PATIENTS This study involved consecutive patients with overt GI bleeding who were treated with n-butyl-2-cyanoacrylate spray during endoscopy for persistent bleeding despite conventional hemostatic therapies. INTERVENTION Cyanoacrylate spray. MAIN OUTCOME MEASUREMENTS Hemostasis, rebleeding, adverse events, and technical failure associated with cyanoacrylate spray. RESULTS Five patients were treated with cyanoacrylate spray during endoscopy for persistent bleeding (duodenal ulcer in 3, gastric vascular ectasia in 1, rectal postpolypectomy bleeding in 1) after failed conventional therapies. Immediate hemostasis and technical success were achieved in all patients. At a median follow-up of 42 days (range 38-120 days), 2 patients developed recurrent bleeding. One patient experienced rebleeding 2 days after the procedure, subsequently requiring radiographic intervention and surgery. Another patient had recurrent bleeding from a different bleeding source 18 days after the procedure. No adverse events attributed to the cyanoacrylate spray were observed. LIMITATIONS Small number of patients. CONCLUSION In patients with difficult-to-control GI bleeding failing conventional endoscopic therapies, cyanoacrylate spray was effective in achieving immediate hemostasis. Prospective studies with a larger number of patients to evaluate the role of the cyanoacrylate spray technique during endoscopy for GI bleeding are needed.
Collapse
Affiliation(s)
- Sukhpreet S Walia
- Division of Gastroenterology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, California 92354, USA
| | | | | | | | | | | |
Collapse
|
79
|
Iwasaki H, Shimura T, Yamada T, Aoki M, Nomura S, Kusakabe A, Kanie H, Ban T, Hayashi K, Joh T, Orito E. Novel nasogastric tube-related criteria for urgent endoscopy in nonvariceal upper gastrointestinal bleeding. Dig Dis Sci 2013; 58:2564-71. [PMID: 23695871 DOI: 10.1007/s10620-013-2706-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/24/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with active upper gastrointestinal bleeding (UGIB) require urgent endoscopy, but appropriate criteria for urgent endoscopy in these patients have not yet been established. AIMS The goal of this study is to establish a simple system for the selection of UGIB patients who may benefit from urgent endoscopy. METHODS Of the 335 patients who required emergency hospitalization for UGIB from May 2010 to March 2012 at Nagoya Daini Red Cross Hospital, 166 patients who underwent placement of a nasogastric tube (NGT) were retrospectively identified. Active bleeding on the endoscopic image was used as an endpoint that reflected the need for urgent endoscopy. RESULTS The ratio of the heart rate to the systolic blood pressure (HR/SBP ratio) and aspiration of fresh or dark red fluid from the NGT [NGT(+)] were significant predictors of active bleeding in the univariate analysis [HR/SBP ratio, P=0.016; NGT(+), P<0.001]. The HR/SBP ratio [odds ratio (OR) 8.118; 95% confidence intervals (CI) 1.696-38.850; P=0.009] and NGT(+) (OR 4.630; 95% CI 2.092-10.204; P<0.001) were also significantly associated with active bleeding in the multivariate analysis. Moreover, receiver operating characteristic analysis revealed a setting with HR/SBP ratio>1.4 or NGT(+) to be optimal criteria to predict active bleeding. These criteria were associated with a sensitivity of 64.9% (24/37) and a specificity of 76.7% (99/129) for the prediction of active bleeding; consequently, they are superior to the sensitivity and specificity of previously proposed criteria. CONCLUSIONS A novel and simple criteria system using NGT(+) and HR/SBP is a good predictor of the need for urgent endoscopy in patients with nonvariceal UGIB.
Collapse
Affiliation(s)
- Hiroyasu Iwasaki
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, 2-9 Myouken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
80
|
Kim YI, Choi IJ, Cho SJ, Lee JY, Kim CG, Kim MJ, Ryu KW, Kim YW, Park YI. Outcome of endoscopic therapy for cancer bleeding in patients with unresectable gastric cancer. J Gastroenterol Hepatol 2013; 28:1489-95. [PMID: 23662891 DOI: 10.1111/jgh.12262] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Gastric cancer bleeding is not rare complication in patients with advanced gastric cancer (AGC). The aim of this study was to evaluate the efficacy and clinical outcomes of endoscopic therapy (ET) for upper gastrointestinal bleeding (UGIB) from unresectable AGC. METHODS Data from 113 patients with UGIB from unresectable AGC who underwent ET at the National Cancer Center, Korea were analyzed retrospectively. Success rates of endoscopic hemostasis, rebleeding rates, mortality at 30 days, and overall survival (OS) rate after initial hemostasis were investigated. RESULTS The initial hemostasis rate was 92.9% (105/113). Electrocoagulation was the most common method used (92.0%, 104/113), and combination ET was required in 34 patients (30.1%). Rebleeding occurred in 43 patients (41.0%); 3-day and 30-day rebleeding rates were 18.1% and 29.5%, respectively. Multivariate logistic regression analysis showed that transfusion of packed red blood cells (> 5 units) was associated with early rebleeding (≤ 3 days after initial hemostasis) (odd ratio, 4.75; 95% confidential interval, 1.45-15.57; P = 0.010). ET was attempted in 18 patients with rebleeding; hemostasis was achieved in 88.9%. The 30-day mortality rate after initial bleeding event was 15.9%. Median OS after initial hemostasis was 3.2 months. OS was lower for patients with early rebleeding than for those with late rebleeding (> 3 days after initial hemostasis) or without rebleeding (1.0, 3.1, and 4.3 months, respectively; P = 0.004). CONCLUSIONS ET, primarily endoscopic electrocoagulation, achieved a high initial hemostasis rate for UGIB in patients with unresectable AGC. However, rebleeding frequently occurred, and early rebleeding was associated with poor survival.
Collapse
Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea; School of Life Sciences and Immune Synapse Research Center, Gwangju Institute of Science and Technology (GIST), Gwangju, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
81
|
Simon EG, Chacko A, Dutta AK, Joseph AJ, George B. Acute nonvariceal upper gastrointestinal bleeding--experience of a tertiary care center in southern India. Indian J Gastroenterol 2013; 32:236-41. [PMID: 23526425 DOI: 10.1007/s12664-013-0305-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 02/02/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Over the last few decades, epidemiologic studies from the West have shown changing trends in etiology and clinical outcomes in patients with nonvariceal upper gastrointestinal bleed (NVUGIB). There are limited data from India on the current status of NVUGIB. The aim of this study therefore was to assess the etiological profile and outcomes of patients with NVUGIB at our center. METHODS We prospectively studied all patients (≥15 years) who presented with NVUGIB over a period of 1 year. The clinical and laboratory data, details of endoscopy, and course in hospital were systematically recorded. Outcome measures assessed were rebleeding rate, surgery, and mortality. RESULTS Two hundred and fourteen patients (age, ≥15 years) presented to us with NVUGIB during the study period. The mean age was 49.9 ± 16.8 years and 73.8 % were males. Peptic ulcer was the commonest cause (32.2 %) of NVUGIB. About one third of patients required endoscopic therapy. Rebleeding occurred in 8.9 % patients, surgery was required in 3.7 %, and mortality rate was 5.1 %. Rebleeding and mortality were significantly higher among inpatients developing acute NVUGIB compared to those presenting directly to the emergency room. CONCLUSIONS Peptic ulcer was the most common cause of NVUGIB. Outcomes (rebleed, surgery, and mortality) at our center appear similar to those currently being reported from the West.
Collapse
Affiliation(s)
- Ebby George Simon
- Clinical Gastroenterology and Hepatology, Christian Medical College, Vellore 632 004, India
| | | | | | | | | |
Collapse
|
82
|
Abstract
Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use antiplatelet agents, non-steroidal anti-inflammatory drugs, and anticoagulants. The management of such patients, especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise the published scientific literature about the management of patients with bleeding peptic ulcers, identify directions for future clinical research, and suggest how mortality can be reduced.
Collapse
Affiliation(s)
- James Y W Lau
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, China.
| | | | | | | | | | | |
Collapse
|
83
|
Rudler M, Cluzel P, Massard J, Menegaux F, Vaillant JC, Martin-Dupray A, Noullet S, Poynard T, Thabut D. Optimal nonsurgical management of peptic ulcer bleeding, including arterial embolization is associated with a mortality below 1%. Clin Res Hepatol Gastroenterol 2013; 37:64-71. [PMID: 22572523 DOI: 10.1016/j.clinre.2012.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 02/07/2012] [Accepted: 03/02/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of high-risk peptic ulcer bleeding (PUB) consists in a high-dose infusion of proton pump inhibitors (PPIs) with double endoscopic treatment. If bleeding recurs, a second endoscopic treatment is required. Surgical management should be performed in case of endoscopic treatment failure, or if a second rebleeding occurs. Arterial embolization of PUB has been shown efficient and safe in small retrospective series, but optimal medical treatment was not used. OBJECTIVE Prospective assessment of the feasibility and the efficacy of arterial embolization of endoscopically unmanageable PUB, after optimal medical treatment. PATIENTS All consecutive patients referred to our intensive care unit (ICU) for high-risk PUB received high-dose PPIs and underwent double endoscopic treatment when possible. Arterial embolization was proposed in primary failure to endoscopic treatment, in case of failure of the second endoscopic treatment, or if a second recurrence occurred. RESULTS One hundred and twenty-eight patients with PUB were enrolled between January 2008 and December 2009. Arterial embolization, performed in 11 patients, was efficient in nine patients. Surgery was performed in two patients (one after inefficient embolization, and one with embolization-related complication). One patient died during hospitalization. CONCLUSION Arterial embolization seems to be efficient for endoscopically unmanageable PUB. In our series, one patient developed severe complication related to the procedure and died. If arterial embolization could be proposed before surgery in case of refractory PUB, large prospective studies are needed.
Collapse
Affiliation(s)
- Marika Rudler
- UPMC, Department of Hepatogastroenterology, La Pitié-Salpêtrière Hospital, Pierre-et-Marie-Curie University, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
84
|
Lau JY. Evidence-based management of patients with acute non-variceal upper gastrointestinal bleeding. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
85
|
Loffroy R, Estivalet L, Cherblanc V, Sottier D, Guiu B, Cercueil JP, Krausé D. Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding. World J Gastrointest Surg 2012; 4:223-7. [PMID: 23467300 PMCID: PMC3587468 DOI: 10.4240/wjgs.v4.i10.223] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 09/15/2012] [Accepted: 10/01/2012] [Indexed: 02/06/2023] Open
Abstract
Acute nonvariceal upper gastrointestinal bleeding (UGIB) is a major medical emergency problem associated with significant morbidity and mortality. Endoscopy is considered the first method of choice to detect and treat UGIB. Endoscopic therapy usually achieves primary hemostasis, but 10%-30% of these patients have repeat bleeding. In patients in whom hemostasis is not achieved with endoscopic techniques, treatment with transcatheter angiographic embolization (TAE) or surgery is needed. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. A large number of studies support the use of TAE as salvage therapy as an alternative to surgery. However, few studies have compared the results of TAE with that of emergency surgery in terms of efficiency, the frequency of repeat bleeding, and complications. Recently, Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment. There were no significant differences in 30 d mortality, complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery. In this commentary, we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB. We also attempt to define the exact role of TAE for acute nonvariceal UGIB.
Collapse
Affiliation(s)
- Romaric Loffroy
- Romaric Loffroy, Louis Estivalet, Violaine Cherblanc, Damien Sottier, Boris Guiu, Jean-Pierre Cercueil, Denis Krausé, Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, 21079 Dijon Cedex, France
| | | | | | | | | | | | | |
Collapse
|
86
|
Second-look endoscopy for bleeding peptic ulcer disease: a decision-effectiveness and cost-effectiveness analysis. J Clin Gastroenterol 2012; 46:e71-5. [PMID: 22298087 PMCID: PMC3343187 DOI: 10.1097/mcg.0b013e3182410351] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Second-look endoscopy after initial therapeutic endoscopy for bleeding peptic ulcer disease may decrease the risk of rebleeding; however, it is not recommended routinely. Understanding conditions under which second-look endoscopy is beneficial might be useful for clinical decision making. METHODS Using a decision model, literature-based probabilities, and Medicare reimbursement costs, we compared routine second-look endoscopy with no second-look endoscopy. We measured rebleeding, need for surgery, hospital mortality, and costs, and calculated the cost to avoid each outcome, expressed as the number needed to treat, along with the cost per outcome prevented. RESULTS In the base case, routine second-look endoscopy reduced rebleeding from 16% to 10% (needed to treat=16) but had no effect on other outcomes. The cost to prevent 1 case of rebleeding was nearly $13,000. Threshold analysis revealed a rebleeding threshold of 31% to neutralize the cost difference between routine second-look endoscopy and no routine second-look endoscopy. If routine second-look endoscopy was 100% effective in preventing rebleeding, then the rebleeding threshold for cost neutrality would be 17.5%. When rebleeding risks after the index endoscopy and second-look endoscopy were simultaneously considered, the cost per bleed prevented ranged from a cost savings of $165 when the respective risks were 25% and 5%, to a cost of nearly $33,000 when the risks were 20% and 15%. CONCLUSIONS The results suggest that routine second-look endoscopy is not indicated after therapeutic endoscopy for bleeding peptic ulcer disease. However, if rebleeding risk is 31% or greater, then routine second-look endoscopy reduces this risk at no additional cost.
Collapse
|
87
|
Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 214] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
|
88
|
Wang YL, Cheng YS, Liu LZ, He ZH, Ding KH. Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage. World J Gastroenterol 2012; 18:4765-70. [PMID: 23002347 PMCID: PMC3442216 DOI: 10.3748/wjg.v18.i34.4765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 02/02/2012] [Accepted: 05/06/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive duodenal ulcer hemorrhage.
METHODS: Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer were admitted to our hospital from 2006 to 2011. Superselective angiography of the celiac and gastroduodenal arteries was performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via a 5 French angiographic catheter or 3 French microcatheter. After ETAE, further superior mesenteric arteriography was undertaken in case collateral circulation supplied areas of the duodenal ulcer. Technical and clinical success rates were analyzed. Changes in the mucous membrane were observed using endoscopy following ETAE.
RESULTS: Angiography showed active bleeding with extravasation of contrast medium in seven cases with a 24% positive rate of celiac artery bleeding, and in 19 cases with a 65.5% rate of gastroduodenal artery bleeding. There were no angiographic signs of bleeding in three patients who underwent endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technical success rate reached 90%. No hemostasis was observed in 27 patients within 30 d after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in two patients who drank a lot of wine who were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized.
CONCLUSION: ETAE is an effective and safe measure to control acute massive bleeding of duodenal ulcer.
Collapse
|
89
|
Kim SY, Hyun JJ, Jung SW, Lee SW. Management of non-variceal upper gastrointestinal bleeding. Clin Endosc 2012; 45:220-3. [PMID: 22977806 PMCID: PMC3429740 DOI: 10.5946/ce.2012.45.3.220] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 07/21/2012] [Accepted: 07/21/2012] [Indexed: 12/14/2022] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is a critical condition that demands a quick and effective medical management. Non-variceal UGIB, especially peptic ulcer bleeding is the most significant cause. Appropriate assessment and treatment have a major influence on the prognosis of patients with UGIB. Initial fluids resuscitation and/or transfusion of red blood cells are necessary in patients with clinical evidence of intravascular volume depletion. Endoscopy is essential for diagnosis and treatment of UGIB, and should be provided within 24 hours after presentation of UGIB. Pre-endoscopic use of intravenous proton pump inhibitor (PPI) can downstage endoscopic signs of hemorrhage. Post-endoscopic use of high-dose intravenous PPI can reduce the risk of rebleeding and further interventions such as repeated endoscopy and surgery. Eradication of Helicobacter pylori and withdrawal of non-steroidal anti-inflammatory drugs are recommended to prevent recurrent bleeding.
Collapse
Affiliation(s)
- Seung Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
90
|
Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, Early DS, Evans JA, Fanelli RD, Foley K, Fukami N, Jain R, Jue TL, Khan KM, Lightdale J, Malpas PM, Maple JT, Pasha S, Saltzman J, Sharaf R, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012; 75:1132-8. [PMID: 22624808 DOI: 10.1016/j.gie.2012.02.033] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
|
91
|
Abstract
This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy.
Collapse
Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut 06520-8019, USA.
| | | |
Collapse
|
92
|
Abstract
The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.
Collapse
Affiliation(s)
- Daniel Blero
- ISPPC, 1 Boulevard Zoé Drion, 6000 Charleroi, Belgium.
| | | |
Collapse
|
93
|
Abstract
Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5-10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.
Collapse
|
94
|
Abstract
Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.
Collapse
Affiliation(s)
- Wadie I Najm
- Department of Family Medicine & Geriatrics, Susan Samueli Center of Integrative Medicine, University of California, Irvine, 101 The City Drive, Building 200, #512, Orange, CA 92868, USA.
| |
Collapse
|
95
|
Abstract
The rate of elective surgery for peptic ulcer disease has been declining steadily over the past 3 decades. During this same period, the rate of emergency ulcer surgery rose by 44%. This means that the gastrointestinal surgeon is likely to be called on to manage the emergent complications of peptic ulcer disease without substantial experience in elective peptic ulcer disease surgery. The goal of this review is to familiarize surgeons with our evolving understanding of the pathogenesis, epidemiology, presentation, and management of peptic ulcer disease in the emergency setting, with a focus on peptic ulcer disease-associated bleeding and perforation.
Collapse
Affiliation(s)
- Constance W Lee
- Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, PO Box 100109, Gainesville, FL 32610-0109, USA
| | | |
Collapse
|
96
|
|
97
|
Abstract
Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce the cost of medical care. This article discusses the important aspects of the diagnosis and treatment of bleeding from ulcers, with a focus on endoscopic therapy.
Collapse
Affiliation(s)
- Thomas O G Kovacs
- CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, VA Greater Los Angeles Healthcare System, CA 90073-1003, USA.
| | | |
Collapse
|
98
|
Chang WC, Liu CH, Hsu HH, Huang GS, Tung HJ, Hsieh TY, Tsai SH, Hsieh CB, Yu CY. Intra-arterial treatment in patients with acute massive gastrointestinal bleeding after endoscopic failure: comparisons between positive versus negative contrast extravasation groups. Korean J Radiol 2011; 12:568-78. [PMID: 21927558 PMCID: PMC3168798 DOI: 10.3348/kjr.2011.12.5.568] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 04/07/2011] [Indexed: 12/18/2022] Open
Abstract
Objective To determine whether treatment outcome is associated with visualization of contrast extravasation in patients with acute massive gastrointestinal bleeding after endoscopic failure. Materials and Methods From January 2007 to December 2009, patients that experienced a first attack of acute gastrointestinal bleeding after failure of initial endoscopy were referred to our interventional department for intra-arterial treatment. We enrolled 79 patients and divided them into two groups: positive and negative extravasation. For positive extravasation, patients were treated by coil embolization; and in negative extravasation, patients were treated with intra-arterial vasopressin infusion. The two groups were compared for clinical parameters, hemodynamics, laboratory findings, endoscopic characteristics, and mortality rates. Results Forty-eight patients had detectable contrast extravasation (positive extravasation), while 31 patients did not (negative extravasation). Fifty-six patients survived from this bleeding episode (overall clinical success rate, 71%). An elevation of hemoglobin level was observed in the both two groups; significantly greater in the positive extravasation group compared to the negative extravasation group. Although these patients were all at high risk of dying, the 90-day mortality rate was significantly lower in the positive extravasation than in the negative extravasation (20% versus 42%, p < 0.05). A multivariate analysis suggested that successful hemostasis (odds ratio [OR] = 28.66) is the most important predictor affecting the mortality in the two groups of patients. Conclusion Visualization of contrast extravasation on angiography usually can target the bleeding artery directly, resulting in a higher success rate to control of hemorrhage.
Collapse
Affiliation(s)
- Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | | | | | | | | | | | | | | | | |
Collapse
|
99
|
Szary NM, Gupta R, Choudhary A, Matteson ML, Arif M, Hammad HT, Bechtold ML. Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis. Scand J Gastroenterol 2011; 46:920-4. [PMID: 21561232 DOI: 10.3109/00365521.2011.568520] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. MATERIALS AND METHODS Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). RESULTS Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85-8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24-0.74, p < 0.01), and a trend for less units of blood transfused (WMD -0.48; 95% CI -0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. CONCLUSIONS Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.
Collapse
Affiliation(s)
- Nicholas M Szary
- Division of Gastroenterology, University of Missouri School of Medicine, Columbia, MO, USA
| | | | | | | | | | | | | |
Collapse
|
100
|
Empiric transcatheter arterial embolization for massive bleeding from duodenal ulcers: efficacy and complications. J Vasc Interv Radiol 2011; 22:911-6. [PMID: 21571546 DOI: 10.1016/j.jvir.2011.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/26/2011] [Accepted: 03/12/2011] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of empiric transcatheter arterial embolization (TAE) for patients with massive bleeding from duodenal ulcers. MATERIALS AND METHODS During January 2000 and December 2009, 59 patients with duodenal ulcer bleeding in whom TAE was attempted after endoscopic therapy failed were retrospectively analyzed. The patients were divided into empiric TAE (n = 36) and identifiable TAE (n = 23) groups according to angiographic findings with or without identification of the bleeding sites. The technical and clinical success rate, recurrent bleeding rate, procedure-related complications, and clinical outcomes were evaluated. RESULTS The technical and clinical success rates of TAE were 100% and 83%. The recurrent bleeding rate, clinical success, duodenal stenosis, and 30-day mortality after TAE were not significantly different between the empiric and identifiable TAE groups. CONCLUSIONS A high rate of technical and clinical success was obtained with empiric TAE comparable to identifiable TAE in patients with massive bleeding from duodenal ulcers. There were no severe complications. Empiric TAE is an effective and safe method when a bleeding site cannot determined by angiography.
Collapse
|